Delay in surgery (13HDC01012)

Over a period of eight months a woman was diagnosed with four
urinary tract infections. Blood tests showed a reduction in the
woman's renal function. The medical centre that the woman was
attending arranged further investigations, including a blood test,
mid-stream urine tests (which showed white and red blood cells but
no bacterial growth (no infection)), and testing for an atypical
organism (which was not detected).

The woman was reviewed again by a GP at the medical centre. The
woman did not report any further dysuria (painful urination), but
she had experienced three episodes of haematuria (blood in the
urine) the previous week. The GP referred the woman to a urologist
at a public hospital

The woman had a CT scan of her abdomen and pelvis which showed a
large right-sided renal carcinoma with associated lymphadenopathy.
The woman's CT scan result was discussed at a multidisciplinary
team meeting and the plan was to proceed to palliative
nephroureterectomy (the surgical removal of a kidney and its
ureter) and regional lymph node dissection if staging interventions
did not show further widespread metastatic disease. The woman then
had a CT scan of her chest.

The woman and her daughter-in-law attended an appointment with a
senior urology registrar. The senior urology registrar advised the
woman's GP that she had booked the woman on the urgent list for the
surgical removal of her kidney. The daughter-in-law understood from
this consultation that the diseased kidney would be removed and
that everything would be fine. She said that they did not discuss
any postoperative treatment with the senior urology registrar, but
were advised that they would do so after the operation.

The woman's surgery was incorrectly entered into the booking
system as semi-urgent instead of urgent. From the date of the
woman's consultation with the senior urology registrar and her
referral for surgery, it was 78 days before the woman underwent
surgery.

The woman's CT scan of her chest was reviewed by the urology
team three days prior to her surgery. The woman had a chest X-ray
eight days before surgery but did not have a further CT scan. The
woman had surgery, but not all of the cancer was surgically
resectable, and results of a CT scan showed evidence of disease
progression and masses in her mediastinum. The woman underwent
radiotherapy and chemotherapy. Her chemotherapy was discontinued
and, sadly, she died.

It was held that the medical centre appropriately managed and
investigated the woman's urinary symptoms.

The district health board breached Right 4(1) as it did not
provide the woman with services with reasonable care and skill by
failing to carry out the woman's surgery within a clinically
appropriate timeframe, and for the failure of its staff to discuss
and consider the woman's chest CT scan report adequately prior to
surgery. Adverse comment was made about the district health board
for the explanation given to the woman about her condition. Adverse
comment was also made about the urologist for not performing a
further staging CT chest scan prior to the woman's
surgery.